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Vargas JC, Bezerra PN, Sequeira M, Oliveira GHD, Pegolo CE, Fiore L, Hamerschlak N, Ferreira PRA. Immune thrombocytopenia associated with lymph node tuberculosis: a case report. Rev Soc Bras Med Trop 2023; 56:e00722023. [PMID: 37493733 PMCID: PMC10367195 DOI: 10.1590/0037-8682-0072-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/22/2023] [Indexed: 07/27/2023] Open
Abstract
Extrapulmonary tuberculosis associated with immune thrombocytopenia (ITP) is extremely rare. A likely association between ITP and pulmonary and lymph node tuberculosis was reported in a 29-year-old male patient. His platelet count decreased to 4,000/µL. Chest tomography revealed mediastinal adenomegaly, lymph node clusters in the aorta, and consolidation in the left upper lung lobe. Immunoglobulin and methylprednisolone were administered intravenously. The histopathology of the left upper lung lobe confirmed tuberculosis. The rifampicin/isoniazid/pyrazinamide/ethambutol regimen was initiated, and the corticosteroids were tapered off. This case suggests an association of tuberculosis with ITP, since the platelet count effectively normalized after tuberculosis treatment.
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Affiliation(s)
- Juliano Córdova Vargas
- Américas Oncologia e Hematologia, Departamento de Hematologia, São Paulo, SP, Brasil
- Hospital Samaritano Higienópolis, Departamento de Hematologia, São Paulo, SP, Brasil
- Hospital Metropolitano da Lapa, Departamento de Hematologia, São Paulo, SP, Brasil
- Centro Universitário São Camilo, Faculdade de Medicina, São Paulo, SP, Brasil
| | | | - Murilo Sequeira
- Centro Universitário São Camilo, Faculdade de Medicina, São Paulo, SP, Brasil
| | | | | | - Lucas Fiore
- Hospital Metropolitano da Lapa, Departamento de Radiologia, São Paulo, SP, Brasil
- Hospital Samaritano Higienópolis, Departamento de Radiologia, São Paulo, SP, Brasil
| | - Nelson Hamerschlak
- Américas Oncologia e Hematologia, Departamento de Hematologia, São Paulo, SP, Brasil
- Hospital Israelita Albert Einstein, Departamento de Hematologia, São Paulo, SP, Brasil
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Systemic lupus erythematosus-complicating immune thrombocytopenia: From pathogenesis to treatment. J Autoimmun 2022; 132:102887. [PMID: 36030136 DOI: 10.1016/j.jaut.2022.102887] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 07/21/2022] [Indexed: 11/24/2022]
Abstract
Immune thrombocytopenia (ITP) is a common hematological manifestation of systemic lupus erythematosus (SLE). The heterogeneity of its clinical characteristics and therapeutic responses reflects a complex pathogenesis. A better understanding of its pathophysiological mechanisms and employing an optimal treatment regimen is therefore important to improve the response rate and prognosis, and avoid unwanted outcomes. Besides glucocorticoids, traditional immunosuppressants (i.e. cyclosporine, mycophenolate mofetil) and intravenous immunoglobulins, new therapies are emerging and promising for the treatment of intractable SLE-ITP, such as thrombopoietin receptor agonists (TPO-RAs), platelet desialylation inhibitors(i.e. oseltamivir), B-cell targeting therapy(i.e. rituximab, belimumab), neonatal Fc receptor(FcRn) inhibitor, spleen tyrosine kinase(Syk) inhibitor and Bruton tyrosine kinase(BTK) inhibitor et al., although more rigorous randomized controlled trials are needed to substantiate their efficacy. In this review, we update our current knowledge on the pathogenesis and treatment of SLE-ITP.
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Novel Therapies to Address Unmet Needs in ITP. Pharmaceuticals (Basel) 2022; 15:ph15070779. [PMID: 35890078 PMCID: PMC9318546 DOI: 10.3390/ph15070779] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 02/04/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune disorder that causes low platelet counts and subsequent bleeding risk. Although current corticosteroid-based ITP therapies are able to improve platelet counts, up to 70% of subjects with an ITP diagnosis do not achieve a sustained clinical response in the absence of treatment, thus requiring a second-line therapy option as well as additional care to prevent bleeding. Less than 40% of patients treated with thrombopoietin analogs, 60% of those treated with splenectomy, and 20% or fewer of those treated with rituximab or fostamatinib reach sustained remission in the absence of treatment. Therefore, optimizing therapeutic options for ITP management is mandatory. The pathophysiology of ITP is complex and involves several mechanisms that are apparently unrelated. These include the clearance of autoantibody-coated platelets by splenic macrophages or by the complement system, hepatic desialylated platelet destruction, and the inhibition of platelet production from megakaryocytes. The number of pathways involved may challenge treatment, but, at the same time, offer the possibility of unveiling a variety of new targets as the knowledge of the involved mechanisms progresses. The aim of this work, after revising the limitations of the current treatments, is to perform a thorough review of the mechanisms of action, pharmacokinetics/pharmacodynamics, efficacy, safety, and development stage of the novel ITP therapies under investigation. Hopefully, several of the options included herein may allow us to personalize ITP management according to the needs of each patient in the near future.
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Provan D, Newland AC. Investigational drugs for immune thrombocytopenia. Expert Opin Investig Drugs 2022; 31:715-727. [DOI: 10.1080/13543784.2022.2075340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Drew Provan
- Centre for Immunology, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London UK
| | - Adrian C Newland
- Centre for Immunology, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London UK
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Changing profile of platelet activity and turnover indices during treatment response of immune thrombocytopenia. Clin Exp Med 2022; 22:595-603. [PMID: 35137341 DOI: 10.1007/s10238-022-00790-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 12/26/2021] [Indexed: 01/19/2023]
Abstract
Both platelet count and function change after treatment of immune thrombocytopenia. Platelet function can be measured by plasma markers, including platelet activity [e.g., soluble P-selectin (sP-selectin) and soluble CD40 ligand (sCD40L)] and platelet turnover markers [e.g., glycocalicin (GC)]. Patients were classified into no response (NR, including new diagnosis), partial response (PR) and complete response (CR). One hundred and sixteen samples (29 CR, 32 PR, 55 NR) from 79 patients were collected. Plasma markers (sP-selectin, sCD40L and GC) were measured by ELISA. Platelet counts and mean platelet volume (MPV) were obtained in the clinical laboratory using GenS System-2. The results showed that responsive patients (PR + CR) had higher levels of sP-selectin (P = 0.026) and sCD40L (P = 0.001). Although there was no difference in MPV (P = 0.077) or GC (P = 0.078), there was a marked decrease of GC index (P < 0.001) in responsive patients. Paired sample analysis showed no difference in sP-selectin, sCD40L, MPV or GC but significant difference in GC index (P = 0.017) between NR and PR. Another paired sample analysis showed no difference in sP-selectin, sCD40L, MPV or GC but significant difference in GC index (P = 0.029) between PR and CR. Patients with refractory and newly diagnosed disease had a significant difference in GC (P = 0.020) and sCD40L (P = 0.001), despite similarly low platelet counts. In conclusion, platelet activity markers (sP-selectin and sCD40L) and GC indices change in parallel with treatment response. Plasma levels of GC and sCD40L may be predictors of treatment response.
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Muralidharan S, Njenga M, Garron T, Bondensgaard K, Paolini JF. Preclinical immunopharmacologic assessment of KPL-404, a novel, humanized, non-depleting antagonistic anti-CD40 monoclonal antibody. J Pharmacol Exp Ther 2022; 381:12-21. [DOI: 10.1124/jpet.121.000881] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 01/10/2022] [Indexed: 11/22/2022] Open
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Platelets in ITP: Victims in Charge of Their Own Fate? Cells 2021; 10:cells10113235. [PMID: 34831457 PMCID: PMC8621961 DOI: 10.3390/cells10113235] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/14/2021] [Accepted: 11/16/2021] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder. The pathophysiological mechanisms leading to low platelet levels in ITP have not been resolved, but at least involve autoantibody-dependent and/or cytotoxic T cell mediated platelet clearance and impaired megakaryopoiesis. In addition, T cell imbalances involving T regulatory cells (Tregs) also appear to play an important role. Intriguingly, over the past years it has become evident that platelets not only mediate hemostasis, but are able to modulate inflammatory and immunological processes upon activation. Platelets, therefore, might play an immuno-modulatory role in the pathogenesis and pathophysiology of ITP. In this respect, we propose several possible pathways in which platelets themselves may participate in the immune response in ITP. First, we will elaborate on how platelets might directly promote inflammation or stimulate immune responses in ITP. Second, we will discuss two ways in which platelet microparticles (PMPs) might contribute to the disrupted immune balance and impaired thrombopoiesis by megakaryocytes in ITP. Importantly, from these insights, new starting points for further research and for the design of potential future therapies for ITP can be envisioned.
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8
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New treatments for primary immune thrombocytopenia. Blood Coagul Fibrinolysis 2021; 33:S8-S11. [PMID: 34654012 DOI: 10.1097/mbc.0000000000001094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune disease leading to a decreased platelet count and an ensuing haemorrhagic risk. First-line treatment against ITP consists in the administration of immunomodulators aimed at decreasing platelet destruction. Up to 70% of individuals with an ITP diagnosis treated with corticosteroids do not achieve a clinical response or demonstrate a high relapse rate, requiring treatment to prevent a haemorrhagic risk. Less than 30% of patients treated with thrombopoietin analogues, 60% of those treated with splenectomy and 20% of those treated with rituximab reach sustained remission in the absence of treatment. Because of these reasons, it is unquestionable that treatment of patients with ITP should be optimized. Through this study, we will review new actual and future options of treatment.
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Bikhet M, Iwase H, Yamamoto T, Jagdale A, Foote JB, Ezzelarab M, Anderson DJ, Locke JE, Eckhoff DE, Hara H, Cooper DKC. What Therapeutic Regimen Will Be Optimal for Initial Clinical Trials of Pig Organ Transplantation? Transplantation 2021; 105:1143-1155. [PMID: 33534529 DOI: 10.1097/tp.0000000000003622] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We discuss what therapeutic regimen might be acceptable/successful in the first clinical trial of genetically engineered pig kidney or heart transplantation. As regimens based on a calcineurin inhibitor or CTLA4-Ig have proved unsuccessful, the regimen we administer to baboons is based on induction therapy with antithymocyte globulin, an anti-CD20 mAb (Rituximab), and cobra venom factor, with maintenance therapy based on blockade of the CD40/CD154 costimulation pathway (with an anti-CD40 mAb), with rapamycin, and a corticosteroid. An anti-inflammatory agent (etanercept) is administered for the first 2 wk, and adjuvant therapy includes prophylaxis against thrombotic complications, anemia, cytomegalovirus, and pneumocystis. Using this regimen, although antibody-mediated rejection certainly can occur, we have documented no definite evidence of an adaptive immune response to the pig xenograft. This regimen could also form the basis for the first clinical trial, except that cobra venom factor will be replaced by a clinically approved agent, for example, a C1-esterase inhibitor. However, none of the agents that block the CD40/CD154 pathway are yet approved for clinical use, and so this hurdle remains to be overcome. The role of anti-inflammatory agents remains unproven. The major difference between this suggested regimen and those used in allotransplantation is the replacement of a calcineurin inhibitor with a costimulation blockade agent, but this does not appear to increase the complications of the regimen.
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Affiliation(s)
- Mohamed Bikhet
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Hayato Iwase
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Takayuki Yamamoto
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Abhijit Jagdale
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jeremy B Foote
- Department of Microbiology and Animal Resources Program, University of Alabama at Birmingham, Birmingham, AL
| | - Mohamed Ezzelarab
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Douglas J Anderson
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jayme E Locke
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Devin E Eckhoff
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Hidetaka Hara
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - David K C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
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Immune Thrombocytopenia: Recent Advances in Pathogenesis and Treatments. Hemasphere 2021; 5:e574. [PMID: 34095758 PMCID: PMC8171374 DOI: 10.1097/hs9.0000000000000574] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 04/08/2021] [Indexed: 11/26/2022] Open
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune disease due to both a peripheral destruction of platelets and an inappropriate bone marrow production. Although the primary triggering factors of ITP remain unknown, a loss of immune tolerance-mostly represented by a regulatory T-cell defect-allows T follicular helper cells to stimulate autoreactive splenic B cells that differentiate into antiplatelet antibody-producing plasma cells. Glycoprotein IIb/IIIa is the main target of antiplatelet antibodies leading to platelet phagocytosis by splenic macrophages, through interactions with Fc gamma receptors (FcγRs) and complement receptors. This allows macrophages to activate autoreactive T cells by their antigen-presenting functions. Moreover, the activation of the classical complement pathway participates to platelet opsonization and also to their destruction by complement-dependent cytotoxicity. Platelet destruction is also mediated by a FcγR-independent pathway, involving platelet desialylation that favors their binding to the Ashwell-Morell receptor and their clearance in the liver. Cytotoxic T cells also contribute to ITP pathogenesis by mediating cytotoxicity against megakaryocytes and peripheral platelets. The deficient megakaryopoiesis resulting from both the humoral and the cytotoxic immune responses is sustained by inappropriate levels of thrombopoietin, the major growth factor of megakaryocytes. The better understanding of ITP pathogenesis has provided important therapeutic advances. B cell-targeting therapies and thrombopoietin-receptor agonists (TPO-RAs) have been used for years. New emerging therapeutic strategies that inhibit FcγR signaling, the neonatal Fc receptor or the classical complement pathway, will deeply modify the management of ITP in the near future.
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Vial G, Gensous N, Duffau P. [The CD40-CD40L axis: Current and future implications in clinical immunology]. Rev Med Interne 2021; 42:722-728. [PMID: 33674076 DOI: 10.1016/j.revmed.2021.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/08/2021] [Accepted: 02/06/2021] [Indexed: 10/22/2022]
Abstract
The CD40-CD40 ligand (CD40L) pathway is a backbone of communication between cells of the immune system. It makes it possible to generate a proinflammatory signal and thus participates in the pathogenesis of dysimmune diseases, transplant rejection and atherosclerosis. Because of this therapeutic target of choice, several generations of anti-CD40L monoclonal antibodies have emerged since the 1990s. The first generation of antibodies was responsible for thromboembolic toxicity for which the mechanisms are starting to be defined. New generations of antibodies were designed to overcome this toxicity and are still being developed in lupus, rheumatoid arthritis, Sjogren's syndrome or immunologic thrombocytopenia. In addition to these targeted therapies, there are data suggesting the impact of several drugs among molecules used in cardiology and clinical immunology on the level of CD40L. The objective of this review is to recall the clinical issues related to the CD40-CD40L axis and to present current or future treatments that block CD40L which would allow clinicians to diversify their options for managing dysimmune diseases.
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Affiliation(s)
- G Vial
- Department of Internal Medicine and Clinical Immunology, University Hospital Centre of Bordeaux, Saint-André Hospital, 33000 Bordeaux, France.
| | - N Gensous
- Department of Internal Medicine and Clinical Immunology, University Hospital Centre of Bordeaux, Saint-André Hospital, 33000 Bordeaux, France
| | - P Duffau
- Department of Internal Medicine and Clinical Immunology, University Hospital Centre of Bordeaux, Saint-André Hospital, 33000 Bordeaux, France; CNRS UMR 5164, Immuno ConcEpT, Bordeaux University, 33076 Bordeaux, France
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Emerging Therapies in Immune Thrombocytopenia. J Clin Med 2021; 10:jcm10051004. [PMID: 33801294 PMCID: PMC7958340 DOI: 10.3390/jcm10051004] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 12/11/2022] Open
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune disorder caused by peripheral platelet destruction and inappropriate bone marrow production. The management of ITP is based on the utilization of steroids, intravenous immunoglobulins, rituximab, thrombopoietin receptor agonists (TPO-RAs), immunosuppressants and splenectomy. Recent advances in the understanding of its pathogenesis have opened new fields of therapeutic interventions. The phagocytosis of platelets by splenic macrophages could be inhibited by spleen tyrosine kinase (Syk) or Bruton tyrosine kinase (BTK) inhibitors. The clearance of antiplatelet antibodies could be accelerated by blocking the neonatal Fc receptor (FcRn), while new strategies targeting B cells and/or plasma cells could improve the reduction of pathogenic autoantibodies. The inhibition of the classical complement pathway that participates in platelet destruction also represents a new target. Platelet desialylation has emerged as a new mechanism of platelet destruction in ITP, and the inhibition of neuraminidase could dampen this phenomenon. T cells that support the autoimmune B cell response also represent an interesting target. Beyond the inhibition of the autoimmune response, new TPO-RAs that stimulate platelet production have been developed. The upcoming challenges will be the determination of predictive factors of response to treatments at a patient scale to optimize their management.
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Tang T, Cheng X, Truong B, Sun L, Yang X, Wang H. Molecular basis and therapeutic implications of CD40/CD40L immune checkpoint. Pharmacol Ther 2020; 219:107709. [PMID: 33091428 DOI: 10.1016/j.pharmthera.2020.107709] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/15/2020] [Indexed: 12/22/2022]
Abstract
The CD40 receptor and its ligand CD40L is one of the most critical molecular pairs of the stimulatory immune checkpoints. Both CD40 and CD40L have a membrane form and a soluble form generated by proteolytic cleavage or alternative splicing. CD40 and CD40L are widely expressed in various types of cells, among which B cells and myeloid cells constitutively express high levels of CD40, and T cells and platelets express high levels of CD40L upon activation. CD40L self-assembles into functional trimers which induce CD40 trimerization and downstream signaling. The canonical CD40/CD40L signaling is mediated by recruitment of TRAFs and NF-κB activation, which is supplemented by signal pathways such as PI3K/AKT, MAPKs and JAK3/STATs. CD40/CD40L immune checkpoint leads to activation of both innate and adaptive immune cells via two-way signaling. CD40/CD40L interaction also participates in regulating thrombosis, tissue inflammation, hematopoiesis and tumor cell fate. Because of its essential role in immune activation, CD40/CD40L interaction has been regarded as an attractive immunotherapy target. In recent years, significant advance has been made in CD40/CD40L-targeted therapy. Various types of agents, including agonistic/antagonistic monoclonal antibodies, cellular vaccines, adenoviral vectors and protein antagonist, have been developed and evaluated in early-stage clinical trials for treating malignancies, autoimmune diseases and allograft rejection. In general, these agents have demonstrated favorable safety and some of them show promising clinical efficacy. The mechanisms of benefits include immune cell activation and tumor cell lysis/apoptosis in malignancies, or immune cell inactivation in autoimmune diseases and allograft rejection. This review provides a comprehensive overview of the structure, processing, cellular expression pattern, signaling and effector function of CD40/CD40L checkpoint molecules. In addition, we summarize the progress, targeted diseases and outcomes of current ongoing and completed clinical trials of CD40/CD40L-targeted therapy.
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Affiliation(s)
- TingTing Tang
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Center for Metabolic Disease Research, Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | - Xiang Cheng
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Billy Truong
- Center for Metabolic Disease Research, Lewis Katz School of Medicine, Temple University, Philadelphia, PA; Department of Microbiology and Immunology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | - LiZhe Sun
- Center for Metabolic Disease Research, Lewis Katz School of Medicine, Temple University, Philadelphia, PA; Department of Cardiovascular Medicine, the First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - XiaoFeng Yang
- Center for Metabolic Disease Research, Lewis Katz School of Medicine, Temple University, Philadelphia, PA; Department of Microbiology and Immunology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | - Hong Wang
- Center for Metabolic Disease Research, Lewis Katz School of Medicine, Temple University, Philadelphia, PA; Department of Microbiology and Immunology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA.
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Tocut M, Shoenfeld Y, Zandman-Goddard G. Systemic lupus erythematosus: an expert insight into emerging therapy agents in preclinical and early clinical development. Expert Opin Investig Drugs 2020; 29:1151-1162. [PMID: 32755494 DOI: 10.1080/13543784.2020.1807004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is a chronic disease that is potentially fatal. There is no cure for SLE and the medications used are associated with toxic side effects. In the era of revolutionary emerging novel biologic agents, the design and investigation of targeted therapy for these patients is necessary. Novel therapies under investigation in phase II-III clinical trials showed promising results. Therapies can target various pathways involved in SLE including cytokines, signal transduction inhibitors, B-cell depletion and interference with co-stimulation. Of interest is the proof of concept of sequential therapy. AREAS COVERED We performed an extensive literature search via PubMed, Medline, Elsevier Science and Springer Link databases between the years 2014-2020 using the following terms: SLE, novel treatments. We have reviewed 232 articles and selected those articles that (i) focus on phase II-III emerging therapies and (ii) offer new findings from existing therapies, which reveal breakthrough concepts in SLE treatment. EXPERT OPINION It is still difficult to crack the puzzle of a successful SLE treatment approach. New strategies with potential may encompass the targeting of more than one protein. Another way forward is to identify each SLE patient and personalize therapy by clinical manifestations, disease activity, serology and activated protein.
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Affiliation(s)
- Milena Tocut
- Department of Internal Medicine C, Wolfson Medical Center , Holon, Israel.,Sackler Faculty of Medicine, Tel-Aviv University , Tel Aviv, Israel
| | - Yehuda Shoenfeld
- Sackler Faculty of Medicine, Tel-Aviv University , Tel Aviv, Israel.,Center for Autoimmune Diseases, Sheba Medical Center , Ramat Gan, Israel.,I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University)
| | - Gisele Zandman-Goddard
- Department of Internal Medicine C, Wolfson Medical Center , Holon, Israel.,Sackler Faculty of Medicine, Tel-Aviv University , Tel Aviv, Israel
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Audia S, Mahevas M, Bonnotte B. [Immune thrombocytopenia: From pathogenesis to treatment]. Rev Med Interne 2020; 42:16-24. [PMID: 32741715 DOI: 10.1016/j.revmed.2020.06.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/29/2020] [Accepted: 06/20/2020] [Indexed: 12/13/2022]
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune disease due to an immune peripheral destruction of platelets and an inappropriate platelet production. The pathogenesis of ITP is now better understood: it involves a humoral immune response which dependents on the stimulation of B cells by specific T cells called T follicular helper cells, leading to their differentiation into plasma cells that produce antiplatelet antibodies thus promoting the phagocytosis of platelets mainly by splenic macrophages. The deciphering of ITP pathogenesis has led to a better understanding of the inefficiency of treatments such as rituximab, although it has not provided yet the determination of biological predictive factor of response to treatments. Moreover, new therapeutic perspectives have been opened in the last few years with the development of molecules targeting Fcγ receptor signalling such as Syk inhibitor, or molecules increasing the clearance of pathogenic autoantibodies such as inhibitors of the neonatal Fc receptor (FcRn).
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Affiliation(s)
- S Audia
- Service de Médecine Interne et Immunologie Clinique, Médecine 1-SOC 1, Hôpital François Mitterrand, Centre de référence des cytopénies auto-immunes de l'adulte, CHU Dijon-Bourgogne, 14 rue Paul Gaffarel, 21079 Dijon, France; Unité RIGHT, INSERM UMR 1098, Équipe "Immunorégulation et immunopathologie", Bâtiment B3, 15 rue Maréchal de Lattre de Tassigny, 21000 Dijon, France.
| | - M Mahevas
- 1 Service de Médecine Interne, Centre National de Référence des Cytopénies Auto-Immunes de l'Adulte, Centre Hospitalier Universitaire Henri-Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France; IMRB - U955 - Equipe n°2 "Transfusion et maladies du globule rouge" EFS Île-de-France, Hôpital Henri-Mondor, AP-HP, 51, avenue du Maréchal-de-Lattre-de-Tassigny, France
| | - B Bonnotte
- Service de Médecine Interne et Immunologie Clinique, Médecine 1-SOC 1, Hôpital François Mitterrand, Centre de référence des cytopénies auto-immunes de l'adulte, CHU Dijon-Bourgogne, 14 rue Paul Gaffarel, 21079 Dijon, France; Unité RIGHT, INSERM UMR 1098, Équipe "Immunorégulation et immunopathologie", Bâtiment B3, 15 rue Maréchal de Lattre de Tassigny, 21000 Dijon, France
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16
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Espié P, He Y, Koo P, Sickert D, Dupuy C, Chokoté E, Schuler R, Mergentaler H, Ristov J, Milojevic J, Verles A, Groenewegen A, Auger A, Avrameas A, Rotte M, Colin L, Tomek CS, Hernandez-Illas M, Rush JS, Gergely P. First-in-human clinical trial to assess pharmacokinetics, pharmacodynamics, safety, and tolerability of iscalimab, an anti-CD40 monoclonal antibody. Am J Transplant 2020; 20:463-473. [PMID: 31647605 DOI: 10.1111/ajt.15661] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/25/2019] [Accepted: 10/09/2019] [Indexed: 01/25/2023]
Abstract
Iscalimab is a fully human, CD40 pathway blocking, nondepleting monoclonal antibody being developed as an immunosuppressive agent. We describe a first-in-human, randomized, double-blind, placebo-controlled study investigating the safety, tolerability, pharmacokinetics, and pharmacodynamics of iscalimab in healthy subjects and rheumatoid arthritis patients. Healthy subjects (n = 56) received single doses of intravenous iscalimab (0.03, 0.1, 0.3, 1, or 3 mg/kg), or subcutaneous iscalimab (3 mg/kg), or placebo. Rheumatoid arthritis patients (n = 20) received single doses of intravenous iscalimab (10 or 30 mg/kg) or placebo. Iscalimab exhibited target-mediated drug disposition resulting in dose-dependent and nonlinear pharmacokinetics. Complete (≥90%) CD40 receptor occupancy on whole blood B cells was observed at plasma concentrations >0.3-0.4 µg/mL. In subjects receiving 3 mg/kg iscalimab, antibody responses to keyhole limpet hemocyanin were transiently suppressed. CD40 occupancy by iscalimab prevented ex vivo human rCD154-induced expression of CD69 on B cells in whole blood. All doses were generally safe and well tolerated, with no clinically relevant changes in any safety parameters, including no evidence of thromboembolic events. Iscalimab appears to be a promising blocker of the CD40-CD154 costimulatory pathway with potential use in transplantation and other autoimmune diseases.
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Affiliation(s)
- Pascal Espié
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - YanLing He
- Novartis Institutes for BioMedical Research, Inc., Cambridge, Massachusetts, USA
| | - Phillip Koo
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Denise Sickert
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Cyrielle Dupuy
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Edwige Chokoté
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Roland Schuler
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | | | - Jacinda Ristov
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Julie Milojevic
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Aurelie Verles
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | | | - Anita Auger
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | | | - Michael Rotte
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Laurence Colin
- Novartis Institutes for BioMedical Research, Inc., Cambridge, Massachusetts, USA
| | | | | | - James S Rush
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Peter Gergely
- Novartis Institutes for BioMedical Research, Basel, Switzerland
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17
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Abstract
Introduction: Immune thrombocytopenia (ITP) is an autoimmune disease. Even though there are many treatments available, some patients remain resistant to multiple treatments. Therefore, it is very important to develop new treatment options. Areas covered: Here, the authors summarize several current and emerging treatments developed for ITP in recent years. They include a summary of their mechanisms of action and clinical trial results. Expert opinion: At present, the first-line treatment of ITP is glucocorticoid and intravenous immunoglobulin (IVIg). Other traditional therapies include splenectomy, thrombopoietin (TPO), rituximab and other immunosuppressive agents. The several emerging treatments developed recently for ITP may change the treatment pattern in the future.
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Affiliation(s)
- Xueqing Dou
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College , Tianjin , PR China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College , Tianjin , PR China
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18
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Ristov J, Espie P, Ulrich P, Sickert D, Flandre T, Dimitrova M, Müller-Ristig D, Weider D, Robert G, Schmutz P, Greutmann B, Cordoba-Castro F, Schneider MA, Warncke M, Kolbinger F, Cote S, Heusser C, Bruns C, Rush JS. Characterization of the in vitro and in vivo properties of CFZ533, a blocking and non-depleting anti-CD40 monoclonal antibody. Am J Transplant 2018; 18:2895-2904. [PMID: 29665205 DOI: 10.1111/ajt.14872] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/23/2018] [Accepted: 04/04/2018] [Indexed: 01/25/2023]
Abstract
The CD40-CD154 costimulatory pathway is essential for T cell-dependent immune responses, development of humoral memory, and antigen presenting cell function. These immune functions have been implicated in the pathology of multiple autoimmune diseases as well as allograft rejection. We have generated CFZ533, a fully human, pathway blocking anti-CD40 monoclonal antibody that has been modified with a N297A mutation to render it unable to mediate Fcγ-dependent effector functions. CFZ533 inhibited CD154-induced activation of human leukocytes in vitro, but failed to induce human leukocyte activation. Additionally, CFZ533 was unable to mediate depletion of human CD40 expressing B cells. In vivo, CFZ533 blocked primary and recall T cell-dependent antibody responses in nonhuman primates and abrogated germinal formation without depleting peripheral blood B cells. We also established a relationship between plasma concentrations of CFZ533 and CD40 pathway-relevant pharmacodynamic effects in tissue. Collectively these data support the scientific rationale and posology for clinical utility of this antibody in select autoimmune diseases and solid organ transplantation.
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Affiliation(s)
- Jacinda Ristov
- Autoimmunity, Transplantation and Inflammation, Novartis Institutes of Biomedical Research, Basel, Switzerland
| | - Pascal Espie
- Translational Medicine, Novartis Institutes of Biomedical Research, Basel, Switzerland
| | - Peter Ulrich
- Translational Medicine, Novartis Institutes of Biomedical Research, Basel, Switzerland
| | - Denise Sickert
- Translational Medicine, Novartis Institutes of Biomedical Research, Basel, Switzerland
| | - Thierry Flandre
- Translational Medicine, Novartis Institutes of Biomedical Research, Basel, Switzerland
| | - Mirela Dimitrova
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Dorothee Müller-Ristig
- Autoimmunity, Transplantation and Inflammation, Novartis Institutes of Biomedical Research, Basel, Switzerland
| | - Doris Weider
- Autoimmunity, Transplantation and Inflammation, Novartis Institutes of Biomedical Research, Basel, Switzerland
| | - Gautier Robert
- Autoimmunity, Transplantation and Inflammation, Novartis Institutes of Biomedical Research, Basel, Switzerland
| | - Patrick Schmutz
- Autoimmunity, Transplantation and Inflammation, Novartis Institutes of Biomedical Research, Basel, Switzerland
| | - Barbara Greutmann
- Translational Medicine, Novartis Institutes of Biomedical Research, Basel, Switzerland
| | | | - Martin A Schneider
- Autoimmunity, Transplantation and Inflammation, Novartis Institutes of Biomedical Research, Basel, Switzerland
| | - Max Warncke
- Autoimmunity, Transplantation and Inflammation, Novartis Institutes of Biomedical Research, Basel, Switzerland
| | - Frank Kolbinger
- Autoimmunity, Transplantation and Inflammation, Novartis Institutes of Biomedical Research, Basel, Switzerland
| | - Serge Cote
- Translational Medicine, Novartis Institutes of Biomedical Research, Basel, Switzerland
| | - Christoph Heusser
- Autoimmunity, Transplantation and Inflammation, Novartis Institutes of Biomedical Research, Basel, Switzerland
| | - Christian Bruns
- Autoimmunity, Transplantation and Inflammation, Novartis Institutes of Biomedical Research, Basel, Switzerland
| | - James S Rush
- Autoimmunity, Transplantation and Inflammation, Novartis Institutes of Biomedical Research, Basel, Switzerland
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19
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Perazzio SF, Soeiro-Pereira PV, Dos Santos VC, de Brito MV, Salu B, Oliva MLV, Stevens AM, de Souza AWS, Ochs HD, Torgerson TR, Condino-Neto A, Andrade LEC. Soluble CD40L is associated with increased oxidative burst and neutrophil extracellular trap release in Behçet's disease. Arthritis Res Ther 2017; 19:235. [PMID: 29052524 PMCID: PMC5649058 DOI: 10.1186/s13075-017-1443-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 09/25/2017] [Indexed: 12/11/2022] Open
Abstract
Background Studies have suggested that soluble factors in plasma from patients with active (aBD) and inactive (iBD) Behçet’s disease (BD) stimulate neutrophil function. Soluble CD40 ligand (sCD40L) is an important mediator of inflammation in BD. Its expression and effect on neutrophil oxidative burst and neutrophil extracellular trap (NET) release have not been characterized. In this study, we sought to investigate the role of plasma and the CD40L pathway on NET release and the oxidative burst profile in patients with aBD and iBD. Methods Neutrophils and peripheral blood mononuclear cells (PBMCs) were obtained from patients with aBD (n = 30), patients with iBD (n = 31), and healthy control subjects (HCs; n = 30). sCD40L plasma concentration was determined in individual samples. A pool of plasma for each group was created. In some experiments, plasma pools were treated with recombinant CD40 (rhCD40-muIg) for sCD40L blockade. NET release and H2O2/O2− production were determined after stimulation with phorbol 12-myristate 13-acetate, sCD40L, or plasma pool. Flow cytometric analysis was performed to evaluate the expression of (1) CD40, Mac-1, and phosphorylated NF-κB p65 on neutrophils and monocytes and (2) CD40L on activated T cells and platelets. CD40L gene expression in PBMCs was determined by qRT-PCR. Results sCD40L plasma levels were significantly higher in patients with iBD (median 17,234, range 2346–19,279 pg/ml) and patients with aBD (median 18,289, range 413–19,883 pg/ml) than in HCs (median 47.5, range 33.7–26.7 pg/ml; p < 0.001). NET release was constitutively increased in BD compared with HC. NET release and H2O2/O2− were higher after stimulation with sCD40L or BD plasma and decreased after sCD40L blockade. Mac-1 expression was constitutively increased in neutrophils of patients with aBD (88.7 ± 13.2% of cells) and patients with iBD (89.2 ± 20.1% of cells) compared with HC (27.1 ± 18.8% of cells; p < 0.01). CD40 expression on phagocytes and CD40L expression on platelets were similar in the three groups. PBMCs as well as nonactivated and activated CD4+ T cells from patients with BD showed higher CD40L expression. Conclusions Plasma from patients with aBD exerts a stimulus on NET release and oxidative burst, probably induced by sCD40L. Electronic supplementary material The online version of this article (doi:10.1186/s13075-017-1443-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sandro Félix Perazzio
- Division of Rheumatology, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Botucatu 740, 3° Andar, 04023-062, Sao Paulo, SP, Brazil. .,Fleury Group - Research and Development, Avenida General Valdomiro de Lima, 508, 04344-070, Sao Paulo, SP, Brazil. .,Seattle Children's Research Institute, University of Washington and Center for Immunity and Immunotherapies, 1900 9th Avenue, JMB-7, Seattle, WA, 98101, USA.
| | - Paulo Vitor Soeiro-Pereira
- Department of Immunology, Institute of Biomedical Sciences, University of Sao Paulo, Avenida Professor Lineu Prestes, 2415, 03178-200, Sao Paulo, SP, Brazil.,Department of Pathology, Federal University of Maranhao, Avenida dos Portugueses, 65065-545, Sao Luiz, MA, Brazil
| | - Viviane Cardoso Dos Santos
- Division of Rheumatology, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Botucatu 740, 3° Andar, 04023-062, Sao Paulo, SP, Brazil
| | - Marlon Vilela de Brito
- Department of Biochemistry and Molecular Biology, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Três de Maio, 100, 5° Andar, 04044-020, Sao Paulo, SP, Brazil
| | - Bruno Salu
- Department of Biochemistry and Molecular Biology, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Três de Maio, 100, 5° Andar, 04044-020, Sao Paulo, SP, Brazil
| | - Maria Luiza Vilela Oliva
- Department of Biochemistry and Molecular Biology, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Três de Maio, 100, 5° Andar, 04044-020, Sao Paulo, SP, Brazil
| | - Anne Margherite Stevens
- Seattle Children's Research Institute, University of Washington and Center for Immunity and Immunotherapies, 1900 9th Avenue, JMB-7, Seattle, WA, 98101, USA
| | - Alexandre Wagner Silva de Souza
- Division of Rheumatology, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Botucatu 740, 3° Andar, 04023-062, Sao Paulo, SP, Brazil.,Fleury Group - Research and Development, Avenida General Valdomiro de Lima, 508, 04344-070, Sao Paulo, SP, Brazil
| | - Hans D Ochs
- Seattle Children's Research Institute, University of Washington and Center for Immunity and Immunotherapies, 1900 9th Avenue, JMB-7, Seattle, WA, 98101, USA
| | - Troy R Torgerson
- Seattle Children's Research Institute, University of Washington and Center for Immunity and Immunotherapies, 1900 9th Avenue, JMB-7, Seattle, WA, 98101, USA
| | - Antonio Condino-Neto
- Department of Immunology, Institute of Biomedical Sciences, University of Sao Paulo, Avenida Professor Lineu Prestes, 2415, 03178-200, Sao Paulo, SP, Brazil
| | - Luis Eduardo Coelho Andrade
- Division of Rheumatology, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Botucatu 740, 3° Andar, 04023-062, Sao Paulo, SP, Brazil.,Fleury Group - Research and Development, Avenida General Valdomiro de Lima, 508, 04344-070, Sao Paulo, SP, Brazil
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20
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Behzad MM, Asnafi AA, Jaseb K, Jalali Far MA, Saki N. Expression of CD markers' in immune thrombocytopenic purpura: prognostic approaches. APMIS 2017; 125:1042-1055. [PMID: 28960510 DOI: 10.1111/apm.12755] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 07/28/2017] [Indexed: 01/19/2023]
Abstract
Immune Thrombocytopenic Purpura (ITP) is a common autoimmune bleeding disorder characterized by a reduction in peripheral blood platelet counts. In this disease, autoantibodies (Auto-Abs) are produced against platelet GPIIb/GPIIIa by B cells, which require interaction with T cells. In this review, the importance of B and T lymphocytes in ITP prognosis has been studied. Relevant literature was identified by a PubMed search (1990-2016) of English-language papers using the terms B and T lymphocyte, platelet, CD markers and immune thrombocytopenic purpura. T and B lymphocytes are the main immune cells in the body. Defective function causes disrupted balance of different subgroups of lymphocytes, and abnormal expression of surface markers of these cells results in self-tolerance dysfunction, as well as induction of Auto-Abs against platelet glycoproteins (PG). Given the role of B and T cells in production of autoantibodies against PG, it can be stated that the detection of changes in CD markers' expression in these cells can be a good approach for assessing prognosis in ITP patients.
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Affiliation(s)
- Masumeh Maleki Behzad
- Research Center of Thalassemia & Hemoglobinopathy, Health research institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ali Amin Asnafi
- Research Center of Thalassemia & Hemoglobinopathy, Health research institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Kaveh Jaseb
- Research Center of Thalassemia & Hemoglobinopathy, Health research institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohammad Ali Jalali Far
- Research Center of Thalassemia & Hemoglobinopathy, Health research institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Najmaldin Saki
- Research Center of Thalassemia & Hemoglobinopathy, Health research institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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21
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Davis LS, Reimold AM. Research and therapeutics-traditional and emerging therapies in systemic lupus erythematosus. Rheumatology (Oxford) 2017; 56:i100-i113. [PMID: 28375452 DOI: 10.1093/rheumatology/kew417] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Indexed: 12/21/2022] Open
Abstract
This review summarizes traditional and emerging therapies for SLE. Evidence suggests that the heterogeneity of SLE is a crucial aspect contributing to the failure of large clinical trials for new targeted therapies. A clearer understanding of the mechanisms driving disease pathogenesis combined with recent advances in medical science are predicted to enable accelerated progress towards improved SLE diagnosis and personalized approaches to treatment.
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Affiliation(s)
- Laurie S Davis
- Rheumatic Diseases Division, Department of Internal Medicine, University of Texas Southwestern Medical Center
| | - Andreas M Reimold
- Rheumatic Diseases Division, Department of Internal Medicine, University of Texas Southwestern Medical Center.,Dallas VA Medical Center, Dallas, TX, USA
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22
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Lambert MP, Gernsheimer TB. Clinical updates in adult immune thrombocytopenia. Blood 2017; 129:2829-2835. [PMID: 28416506 PMCID: PMC5813736 DOI: 10.1182/blood-2017-03-754119] [Citation(s) in RCA: 245] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 04/10/2017] [Indexed: 12/25/2022] Open
Abstract
Immune thrombocytopenia (ITP) occurs in 2 to 4/100 000 adults and results in variable bleeding symptoms and thrombocytopenia. In the last decade, changes in our understanding of the pathophysiology of the disorder have led to the publication of new guidelines for the diagnosis and management of ITP and standards for terminology. Current evidence supports alternatives to splenectomy for second-line management of patients with persistently low platelet counts and bleeding. Long-term follow-up data suggest both efficacy and safety, in particular, for the thrombopoietin receptor agonists and the occurrence of late remissions. Follow-up of patients who have undergone splenectomy for ITP reveals significant potential risks that should be discussed with patients and may influence clinician and patient choice of second-line therapy. Novel therapeutics are in development to address ongoing treatment gaps.
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MESH Headings
- Adult
- Female
- Hemorrhage/blood
- Hemorrhage/diagnosis
- Hemorrhage/physiopathology
- Hemorrhage/therapy
- Humans
- Male
- Platelet Count
- Practice Guidelines as Topic
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/physiopathology
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Receptors, Thrombopoietin/agonists
- Receptors, Thrombopoietin/metabolism
- Splenectomy
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Affiliation(s)
- Michele P Lambert
- Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, PA; and
| | - Terry B Gernsheimer
- Division of Hematology, University of Washington School of Medicine, Seattle, WA
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23
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24
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Affiliation(s)
- Abdulgabar Salama
- Charité - Universitätsmedizin Berlin, Germany - Institute of Transfusion Medicine, Berlin, Germany
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25
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Consolini R, Costagliola G, Spatafora D. The Centenary of Immune Thrombocytopenia-Part 2: Revising Diagnostic and Therapeutic Approach. Front Pediatr 2017; 5:179. [PMID: 28871277 PMCID: PMC5566994 DOI: 10.3389/fped.2017.00179] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 08/07/2017] [Indexed: 01/19/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is the most common cause of thrombocytopenia in children and adolescents and can be considered as a paradigmatic model of autoimmune disease. This second part of our review describes the clinical presentation of ITP, the diagnostic approach and overviews the current therapeutic strategies. Interestingly, it suggests an algorithm useful for differential diagnosis, a crucial process to exclude secondary forms of immune thrombocytopenia (IT) and non-immune thrombocytopenia (non-IT), which require a different therapeutic management. Advances in understanding the pathogenesis led to new therapeutic targets, as thrombopoietin receptor agonists, whose role in treatment of ITP will be discussed in this work.
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Affiliation(s)
- Rita Consolini
- Laboratory of Immunology, Department of Clinical and Experimental Medicine, Division of Pediatrics, University of Pisa, Pisa, Italy
| | - Giorgio Costagliola
- Laboratory of Immunology, Department of Clinical and Experimental Medicine, Division of Pediatrics, University of Pisa, Pisa, Italy
| | - Davide Spatafora
- Clinical Immunology and Allergy Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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26
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Moukhadder HM, Chaya BF, Bazarbachi AHA, Taher AT. Immune thrombocytopenia: a comprehensive review from pathophysiology to promising treatment modalities. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1247691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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27
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Nomura S. Advances in Diagnosis and Treatments for Immune Thrombocytopenia. Clin Med Insights Blood Disord 2016; 9:15-22. [PMID: 27441004 PMCID: PMC4948655 DOI: 10.4137/cmbd.s39643] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 05/22/2016] [Accepted: 05/24/2016] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is an acquired hemorrhagic condition characterized by the accelerated clearance of platelets caused by antiplatelet autoantibodies. A platelet count in peripheral blood <100 × 109/L is the most important criterion for the diagnosis of ITP. However, the platelet count is not the sole diagnostic criterion, and the diagnosis of ITP is dependent on additional findings. ITP can be classified into three types, namely, acute, subchronic, and persistent, based on disease duration. Conventional therapy includes corticosteroids, intravenous immunoglobulin, splenectomy, and watch-and-wait. Second-line treatments for ITP include immunosuppressive therapy [eg, anti-CD20 (rituximab)], with international guidelines, including rituximab as a second-line option. The most recently licensed drugs for ITP are the thrombopoietin receptor agonists (TRAs), such as romiplostim and eltrombopag. TRAs are associated with increased platelet counts and reductions in the number of bleeding events. TRAs are usually considered safe, effective treatments for patients with chronic ITP at risk of bleeding after failure of first-line therapies. Due to the high costs of TRAs, however, it is unclear if patients prefer these agents. In addition, some new agents are under development now. This manuscript summarizes the pathophysiology, diagnosis, and treatment of ITP. The goal of all treatment strategies for ITP is to achieve a platelet count that is associated with adequate hemostasis, rather than a normal platelet count. The decision to treat should be based on the bleeding severity, bleeding risk, activity level, likely side effects of treatment, and patient preferences.
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Affiliation(s)
- Shosaku Nomura
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Osaka, Japan
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28
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Neschadim A, Branch DR. Mouse Models for Immune-Mediated Platelet Destruction or Immune Thrombocytopenia (ITP). ACTA ACUST UNITED AC 2016; 113:15.30.1-15.30.13. [PMID: 27038460 DOI: 10.1002/0471142735.im1530s113] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is a debilitating, life-threatening autoimmune disorder affecting more than 4 in every 100,000 adults annually, stemming from the production of antiplatelet antibody resulting in accelerated platelet destruction and thrombocytopenia. Numerous animal models of ITP have been developed that contributed to the basic understanding of the underlying mechanisms of ITP onset, progression, and maintenance. Rodent models that develop ITP spontaneously, or by passive transfer of an antiplatelet sera or antibody, play an instrumental role in the investigation of ITP mechanisms responsible for the breakdown of tolerance in human ITP, in studies of the immunopathology underlying the progression of platelet destruction, and in elucidation of the mechanisms of therapeutic amelioration of ITP by existing and new therapeutic modalities. This unit captures the protocols for the implementation and readout of passive antibody transfer mouse models of ITP, established by the infusion of a commercially-available monoclonal rat anti-mouse CD41 platelet antibody.
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Affiliation(s)
- Anton Neschadim
- Centre for Innovation, Canadian Blood Services, Toronto, Ontario, Canada
| | - Donald R Branch
- Centre for Innovation, Canadian Blood Services, Toronto, Ontario, Canada.,Departments of Medicine and Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Division of Advanced Diagnostics, Infection and Immunity Group, Toronto General Research Institute, Toronto, Ontario, Canada
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29
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Gupta S, Brennan D. Pneumococcal 13-Valent Conjugate Vaccine (Prevnar 13)-Associated Immune Thrombocytopenic Purpura in a Renal Transplant Recipient: A Case Report. Transplant Proc 2016; 48:262-4. [DOI: 10.1016/j.transproceed.2015.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 12/10/2015] [Indexed: 11/28/2022]
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30
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Song I, Kim J, Kwon K, Koo S, Jo D. Expression of CD154 (CD40L) on stimulated T lymphocytes in patients with idopathic thrombocytopenic purpura. Hematology 2015; 21:187-92. [DOI: 10.1179/1607845415y.0000000032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Affiliation(s)
- Ikchan Song
- Department of Hemato-Oncology, Chungnam National University Hospital, 282 Moonhwa-ro, Joong-gu, Daejeon 301-721, South Korea
| | - Jimyung Kim
- Department of Laboratory Medicine, Chungnam National University Hospital, 282 Moonhwa-ro, Joong-gu, Daejeon 301-721, South Korea
| | - Kyechul Kwon
- Department of Laboratory Medicine, Chungnam National University Hospital, 282 Moonhwa-ro, Joong-gu, Daejeon 301-721, South Korea
| | - Sunhoe Koo
- Department of Laboratory Medicine, Chungnam National University Hospital, 282 Moonhwa-ro, Joong-gu, Daejeon 301-721, South Korea
| | - Dukyeon Jo
- Department of Hemato-Oncology, Chungnam National University Hospital, 282 Moonhwa-ro, Joong-gu, Daejeon 301-721, South Korea
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31
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Bakchoul T, Sachs UJ. Platelet destruction in immune thrombocytopenia. Understanding the mechanisms. Hamostaseologie 2015; 36:187-94. [PMID: 25982994 DOI: 10.5482/hamo-14-09-0043] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Accepted: 05/04/2015] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder characterized by isolated thrombocytopenia. A dysfunctional proliferation of autoreactive T cells is suggested to be responsible for the loss of tolerance to self-platelet antigens in ITP patients. Autoreactive T cells induce uncontrolled proliferation of autoantibody producing B cells leading to persistent anti-platelet autoimmunity in some ITP patients. The autoimmune response causes an increased destruction of platelets by antibody-mediated phagocytosis, complement activation but also by T cell mediated cytotoxicity. In addition, abnormalities in thrombopoiesis and insufficient platelet production due to antibody or T cell mediated megakaryocyte inhibition and destruction contribute to the pathophysiology of ITP. These various effector cell responses may account for the heterogeneity in the clinical manifestation of ITP and also, to success or failure of different treatment strategies. A better understanding of the mechanisms behind ITP will hopefully allow for better diagnostic and, particularly, therapeutic strategies in the future.
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Affiliation(s)
- Tamam Bakchoul
- Prof. Dr. med. Tamam Bakchoul, Institute for Immunology and Transfusion Medicine, Universitätsmedizin Greifswald, Ferdinand-Sauerbruch-Straße, 17475 Greifswald, Germany, Tel. +49/(0)38 34/86 54 58, Fax +49/(0)38 34/86 54 89, E-mail:
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Takeuchi Y, Takeuchi E, Ishida T, Onodera M, Nakauchi H, Otsu M. Curative haploidentical BMT in a murine model of X-linked chronic granulomatous disease. Int J Hematol 2015; 102:111-20. [PMID: 25921405 DOI: 10.1007/s12185-015-1799-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 04/09/2015] [Accepted: 04/13/2015] [Indexed: 10/23/2022]
Abstract
Chronic granulomatous disease (CGD) is a primary immunodeficiency disorder characterized by defective microbial killing in phagocytes. Long-term prognosis for CGD patients is generally poor, highlighting the need to develop minimally toxic, curative therapeutic approaches. We here describe the establishment of a mouse model in which X-linked CGD can be cured by allogeneic bone marrow transplantation. Using a combination of non-myeloablative-dose total body irradiation and a single injection of anti-CD40 ligand monoclonal antibody, transplantation of whole bone marrow cells achieved long-lasting mixed chimerism in X-linked CGD mice in a haploidentical transplantation setting. Stable mixed chimerism was maintained for up to 1 year even at a low range (<20 % donor cells), indicating induction of donor-specific tolerance. The regimen induced mild myelosuppression without severe acute complications. Stable chimerism was therapeutic, as it suppressed cutaneous granuloma formation in an in vivo test suited for evaluation of treatment efficacy in murine CGD models. These results warrant future development of a simplified allogeneic hematopoietic cell transplantation regimen that would benefit CGD patients by allowing the use of haploidentical donor grafts without serious concerns of severe treatment-related toxicity.
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Affiliation(s)
- Yasuo Takeuchi
- Division of Nephrology, Department of Internal Medicine, Kitasato University School of Medicine, Sagamihara, Japan
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Tocoian A, Buchan P, Kirby H, Soranson J, Zamacona M, Walley R, Mitchell N, Esfandiari E, Wagner F, Oliver R. First-in-human trial of the safety, pharmacokinetics and immunogenicity of a PEGylated anti-CD40L antibody fragment (CDP7657) in healthy individuals and patients with systemic lupus erythematosus. Lupus 2015; 24:1045-56. [PMID: 25784719 DOI: 10.1177/0961203315574558] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 01/15/2015] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The objective of this paper is to investigate the safety, pharmacokinetics (PK) and immunogenicity of CDP7657, a PEGylated anti-CD40L antibody fragment, in healthy individuals and patients with systemic lupus erythematosus (SLE). METHODS This randomized, double-blind, single-dose, dose-escalation phase I study consisted of two parts. In part 1, 28 healthy individuals received CDP7657 IV (0.004-5 mg/kg) or placebo. In part 2, 17 patients with SLE received CDP7657 IV (5-60 mg/kg) or placebo. The CDP7657:placebo ratio was 3:1. RESULTS Adverse events (AEs) were reported by 76% of healthy individuals and 100% of patients with SLE treated with CDP7657; most were mild or moderate in intensity. Two healthy individuals reported serious AEs (SAEs), one of which was considered treatment related (infusion-related reaction; 5 mg/kg cohort). One patient with SLE (60 mg/kg cohort) experienced three SAEs, one of which was considered treatment related (herpes zoster infection). No thromboembolic events were reported. CPD7657 exposure increased in a dose-proportional manner. Low anti-CDP7657 antibody titres were detected in the majority of CDP7657-treated participants with no apparent impact on the PK of CDP7657. CONCLUSION Single doses of CDP7657 showed predictable PK in healthy individuals and patients with SLE and were well tolerated, with no safety signals of concern. These findings support further investigation of CDP7657 as a therapy for SLE.
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Affiliation(s)
| | | | | | | | | | | | | | | | - F Wagner
- Charité Research Organisation GmbH, Germany
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Wong RSM, Bakshi K, Brainsky A. Thrombophilia in patients with chronic immune thrombocytopenia. Scandinavian Journal of Clinical and Laboratory Investigation 2014; 75:13-7. [PMID: 25296772 DOI: 10.3109/00365513.2014.962597] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
An increased risk of thromboembolic events among patients with chronic immune thrombocytopenia has been reported but is still not fully understood. A thrombophilia panel (factors suspected/known to denote a thrombophilic state or indicate activation of the clotting cascade) was measured in previously treated patients with chronic immune thrombocytopenia enrolled in an eltrombopag trial to assess potential thrombophilia risk markers. Of 167 patients, 136 (81%) had abnormal levels of at least 1 known or suspected thrombosis risk marker or coagulation cascade activation marker. Six patients reported thromboembolic events, and all of these patients had at least two abnormal analytes in the thrombophilia panel. The presence of multiple baseline thrombophilia risk markers support the theory that chronic immune thrombocytopenia is a pro-thrombotic disease.
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Affiliation(s)
- Raymond S M Wong
- Prince of Wales Hospital, The Chinese University of Hong Kong, Department of Medicine and Therapeutics , Hong Kong , China
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Splenic TFH expansion participates in B-cell differentiation and antiplatelet-antibody production during immune thrombocytopenia. Blood 2014; 124:2858-66. [PMID: 25232056 DOI: 10.1182/blood-2014-03-563445] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Antiplatelet-antibody-producing B cells play a key role in immune thrombocytopenia (ITP) pathogenesis; however, little is known about T-cell dysregulations that support B-cell differentiation. During the past decade, T follicular helper cells (TFHs) have been characterized as the main T-cell subset within secondary lymphoid organs that promotes B-cell differentiation leading to antibody class-switch recombination and secretion. Herein, we characterized TFHs within the spleen of 8 controls and 13 ITP patients. We show that human splenic TFHs are the main producers of interleukin (IL)-21, express CD40 ligand (CD154), and are located within the germinal center of secondary follicles. Compared with controls, splenic TFH frequency is higher in ITP patients and correlates with germinal center and plasma cell percentages that are also increased. In vitro, IL-21 stimulation combined with an anti-CD40 agonist antibody led to the differentiation of splenic B cells into plasma cells and to the secretion of antiplatelet antibodies in ITP patients. Overall, these results point out the involvement of TFH in ITP pathophysiology and the potential interest of IL-21 and CD40 as therapeutic targets in ITP.
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Shih A, Nazi I, Kelton JG, Arnold DM. Novel treatments for immune thrombocytopenia. Presse Med 2014; 43:e87-95. [PMID: 24656294 PMCID: PMC4880474 DOI: 10.1016/j.lpm.2014.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Revised: 02/05/2014] [Accepted: 02/10/2014] [Indexed: 01/19/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is caused by platelet autoantibodies and T-cell dysregulation. Both platelets and their precursor megakaryocytes may be targeted leading to platelet destruction and underproduction. Current treatments for ITP are inadequate since they do not reverse the disease process and generally do not result in durable remissions. In addition, many treatments are limited by side effects including infection and potentially thrombosis. Novel agents that are currently in development target certain key steps in the disease process, including: (1) the interaction between T-cell and antigen presenting cells (CD40-CD154 interaction); (2) the binding of the Fc portion of platelet autoantibodies to Fc-receptors on macrophages (soluble Fc-RIIb); and (3) the signaling pathways leading to platelet phagocytosis by macrophages (Syk inhibition). Other strategies have been to augment platelet production by simulating thrombopoiesis or by neutralizing physiological inhibitors of megakaryopoiesis. Targeted therapies in ITP have the potential to improve disease morbidity and mortality while limiting systemic side effects. Before these agents can be used in practice, additional clinical studies are needed with rational study outcomes including platelet count, bleeding and quality of life. An individualized treatment strategy is needed for patients since ITP is a distinctly heterogeneous disease.
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Affiliation(s)
- Andrew Shih
- McMaster University, Department of Medicine, Hamilton, Ontario, Canada
| | - Ishac Nazi
- McMaster University, Department of Medicine, Hamilton, Ontario, Canada
| | - John G Kelton
- McMaster University, Department of Medicine, Hamilton, Ontario, Canada
| | - Donald M Arnold
- McMaster University, Department of Medicine, Hamilton, Ontario, Canada; Canadian Blood Services, Hamilton, Ontario, Canada.
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Xie JH, Yamniuk AP, Borowski V, Kuhn R, Susulic V, Rex-Rabe S, Yang X, Zhou X, Zhang Y, Gillooly K, Brosius R, Ravishankar R, Waggie K, Mink K, Price L, Rehfuss R, Tamura J, An Y, Cheng L, Abramczyk B, Ignatovich O, Drew P, Grant S, Bryson JW, Suchard S, Salter-Cid L, Nadler S, Suri A. Engineering of a Novel Anti-CD40L Domain Antibody for Treatment of Autoimmune Diseases. THE JOURNAL OF IMMUNOLOGY 2014; 192:4083-92. [DOI: 10.4049/jimmunol.1303239] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Abstract
Inhibitors of tumour necrosis factor (TNF) are among the most successful protein-based drugs (biologics) and have proven to be clinically efficacious at reducing inflammation associated with several autoimmune diseases. As a result, attention is focusing on the therapeutic potential of additional members of the TNF superfamily of structurally related cytokines. Many of these TNF-related cytokines or their cognate receptors are now in preclinical or clinical development as possible targets for modulating inflammatory diseases and cancer as well as other indications. This Review focuses on the biologics that are currently in clinical trials for immune-related diseases and other syndromes, discusses the successes and failures to date as well as the expanding therapeutic potential of modulating the activity of this superfamily of molecules.
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Affiliation(s)
- Michael Croft
- Division of Immune Regulation, La Jolla Institute for Allergy and Immunology, La Jolla, California 92037, USA.
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Neunert CE. Current management of immune thrombocytopenia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2013; 2013:276-282. [PMID: 24319191 DOI: 10.1182/asheducation-2013.1.276] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune-mediated condition that results from antibody-mediated destruction of platelets and impaired megakaryocyte platelet production. ITP patients exhibit severe thrombocytopenia and are at risk for significant hemorrhage. Few randomized trials exist to guide management of patients with ITP. Ultimately, each patient requires an individualized treatment plan that takes into consideration the platelet count, bleeding symptoms, health-related quality of life, and medication side effects. This article provides an up-to-date review of management strategies drawing on links between the expanding amounts of clinical trial data and associated biology studies to enhance understanding of the disease heterogeneity with regard to the complex pathogenesis and response to treatment.
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Affiliation(s)
- Cindy E Neunert
- 1Department of Pediatrics and Cancer Center, Georgia Regents University, Augusta, GA
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Safety and efficacy of eltrombopag for treatment of chronic immune thrombocytopenia: results of the long-term, open-label EXTEND study. Blood 2012; 121:537-45. [PMID: 23169778 DOI: 10.1182/blood-2012-04-425512] [Citation(s) in RCA: 217] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Patients with chronic immune thrombocytopenia may have bleeding resulting from low platelet counts. Eltrombopag increases and maintains hemostatic platelet counts; however, to date, outcome has been reported only for treatment lasting ≤ 6 months. This interim analysis of the ongoing open-label EXTEND (Eltrombopag eXTENded Dosing) study evaluates the safety and efficacy of eltrombopag in 299 patients treated up to 3 years. Splenectomized and nonsplenectomized patients achieved platelets ≥ 50 000/μL at least once (80% and 88%, respectively). Platelets ≥ 50 000/μL and 2 × baseline were maintained for a median of 73 of 104 and 109 of 156 cumulative study weeks, respectively. Bleeding symptoms (World Health Organization Grades 1-4) decreased from 56% of patients at baseline to 20% at 2 years and 11% at 3 years. One hundred (33%) patients were receiving concomitant treatments at study entry, 69 of whom attempted to reduce them; 65% (45 of 69) had a sustained reduction or permanently stopped ≥ 1 concomitant treatment. Thirty-eight patients (13%) experienced ≥ 1 adverse events leading to study withdrawal, including patients meeting protocol-defined withdrawal criteria (11 [4%] thromboembolic events, 5 [2%] exceeding liver enzyme thresholds). No new or increased incidence of safety issues was identified. Long-term treatment with eltrombopag was generally safe, well tolerated, and effective in maintaining platelet counts in the desired range.
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Anoop P. Immune thrombocytopenic purpura: historical perspective, current status, recent advances and future directions. Indian Pediatr 2012; 49:811-8. [PMID: 23144100 DOI: 10.1007/s13312-012-0195-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Immune thrombocytopenic purpura (ITP) has witnessed many changes and updates over the past decade. The definitions of disease subtypes, course and response to treatment have all been standardized recently. Consequent to the lack of an international consensus management guideline, wide variations exist in treatment practice. This is now being addressed to an extent by the much awaited ITP International Working Group 2010 recommendations. The pathophysiologic mechanisms have been unfolded at cellular, molecular and humoral levels. As a result, many recent advances have taken place in the management of this disorder. This review revisits the history of evolution of ITP, summarizes the current recommendations for management and lists the recent advances and future prospects in this field.
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Affiliation(s)
- P Anoop
- Department of Pediatric Hemato-Oncology, Great Ormond Street Hospital for Children, London, United Kingdom.
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Cooper N, Stasi R, Cunningham-Rundles S, Cesarman E, McFarland JG, Bussel JB. Platelet-associated antibodies, cellular immunity and FCGR3a genotype influence the response to rituximab in immune thrombocytopenia. Br J Haematol 2012; 158:539-47. [DOI: 10.1111/j.1365-2141.2012.09184.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2011] [Accepted: 04/24/2012] [Indexed: 12/25/2022]
Affiliation(s)
- Nichola Cooper
- Department of Haematology; Hammersmith Hospital; Imperial Health Care NHS Trust; London; UK
| | - Roberto Stasi
- Department of Haematology; St George's Hospital; London; UK
| | | | - Ethel Cesarman
- Departments of Pediatrics and Pathology; Weill Medical College of Cornell University; New York; NY; USA
| | | | - James B. Bussel
- Departments of Pediatrics and Pathology; Weill Medical College of Cornell University; New York; NY; USA
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Lo MS, Tsokos GC. Treatment of systemic lupus erythematosus: new advances in targeted therapy. Ann N Y Acad Sci 2012; 1247:138-52. [PMID: 22236448 DOI: 10.1111/j.1749-6632.2011.06263.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Treatment for systemic lupus erythematosus (SLE) has traditionally been restricted to broad-based immunosuppression, with glucocorticoids being central to care. Recent insights into lupus pathogenesis promise new, selective therapies with more favorable side effect profiles. The best example of this is belimumab, which targets the B cell cytokine BLyS and has now received Food and Drug Administration (FDA) approval for its use in SLE. Strategies targeting other cytokines, such as interleukin 6 (IL-6) and interferon (IFN)-α, are also on the horizon. Blockade of costimulatory interactions between immune cells offers another opportunity for therapeutic intervention, as do small molecule inhibitors that interfere with cell signaling pathways. We review here the current strategies for SLE treatment, with particular focus on therapies now in active pharmaceutical development. We will also discuss new understandings in lupus pathogenesis that may lead to future advances in therapy.
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Affiliation(s)
- Mindy S Lo
- Division of Immunology, Children's Hospital Boston, Boston, Massachusetts, USA
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Affiliation(s)
- Roberto Stasi
- Department of Haematology, St George’s Hospital, London
| | - Adrian C. Newland
- Department of Haematology, Barts and the London NHS Trust, London, UK
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[Pathophysiology of immune thrombocytopenia]. Rev Med Interne 2010; 32:350-7. [PMID: 20557985 DOI: 10.1016/j.revmed.2009.05.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Revised: 04/09/2009] [Accepted: 05/02/2009] [Indexed: 01/15/2023]
Abstract
Immune thrombocytopenia is an autoimmune disease characterized by a peripheral destruction of platelets. B lymphocytes play a key role but pathogenesis is more complex, involving humoral and cellular immunity associated with an inappropriate platelet production. In this article, we review the different pathogenic pathways, leading to new therapeutic strategies.
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Felix NJ, Suri A, Salter-Cid L, Nadler SG, Gujrathi S, Corbo M, Aranda R. Targeting lymphocyte co-stimulation: From bench to bedside. Autoimmunity 2010; 43:514-25. [PMID: 20429850 DOI: 10.3109/08916931003674741] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Nathan J Felix
- Department of Immunology, Bristol-Myers Squibb Co., Princeton, NJ 08543, USA.
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Hansel TT, Kropshofer H, Singer T, Mitchell JA, George AJT. The safety and side effects of monoclonal antibodies. Nat Rev Drug Discov 2010; 9:325-38. [PMID: 20305665 DOI: 10.1038/nrd3003] [Citation(s) in RCA: 717] [Impact Index Per Article: 51.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Monoclonal antibodies (mAbs) are now established as targeted therapies for malignancies, transplant rejection, autoimmune and infectious diseases, as well as a range of new indications. However, administration of mAbs carries the risk of immune reactions such as acute anaphylaxis, serum sickness and the generation of antibodies. In addition, there are numerous adverse effects of mAbs that are related to their specific targets, including infections and cancer, autoimmune disease, and organ-specific adverse events such as cardiotoxicity. In March 2006, a life-threatening cytokine release syndrome occurred during a first-in-human study with TGN1412 (a CD28-specific superagonist mAb), resulting in a range of recommendations to improve the safety of initial human clinical studies with mAbs. Here, we review some of the adverse effects encountered with mAb therapies, and discuss advances in preclinical testing and antibody technology aimed at minimizing the risk of these events.
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Affiliation(s)
- Trevor T Hansel
- Imperial Clinical Respiratory Research Unit, St Mary's Hospital, Paddington, London, UK.
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Peters AL, Stunz LL, Bishop GA. CD40 and autoimmunity: the dark side of a great activator. Semin Immunol 2009; 21:293-300. [PMID: 19595612 DOI: 10.1016/j.smim.2009.05.012] [Citation(s) in RCA: 200] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2009] [Accepted: 05/26/2009] [Indexed: 02/06/2023]
Abstract
CD40 is a tumor necrosis factor receptor superfamily member expressed by immune and non-immune cells. CD40:CD154 interactions mediate T-dependent B cell responses and efficient T cell priming. Thus, CD40 is a likely candidate to play roles in autoimmune diseases in which activated T and B cells cause pathology. Diseases in which CD40 plays a pathogenic role include autoimmune thyroiditis, type 1 diabetes, inflammatory bowel disease, psoriasis, multiple sclerosis, rheumatoid arthritis, and systemic lupus erythematosus. This review discusses the role of CD40:CD154 interaction in human and mouse autoimmunity, human polymorphisms associated with disease incidence, and disrupting CD40:CD154 interactions as an autoimmune therapy.
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Affiliation(s)
- Anna L Peters
- Immunology Graduate Program and Medical Scientist Training Program, University of Iowa, Iowa City, IA 52242, USA
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Hu C, Wong FS, Wen L. Translational Mini-Review Series on B Cell-Directed Therapies: B cell-directed therapy for autoimmune diseases. Clin Exp Immunol 2009; 157:181-90. [PMID: 19604257 DOI: 10.1111/j.1365-2249.2009.03977.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
B cells play an important role in the pathogenesis of both systemic and organ-specific autoimmune diseases. Autoreactive B cells not only produce autoantibodies, but are also specialized to present specific autoantigens efficiently to T cells. Furthermore, these B cells can secrete proinflammatory cytokines and can amplify the vicious cycle of self-destruction. Thus, B cell-directed therapies are potentially an important approach for treating autoimmune diseases. On the other hand, like T cells, there are subsets of B cells that produce anti-inflammatory cytokines and are immunosuppressive. These regulatory B cell subsets can protect against and ameliorate autoimmune diseases. Thus targeting B cells therapeutically will require this balance to be considered. Here we summarize the roles of pathogenic and regulatory B cells and current applications of B cell-directed therapy in autoimmune diseases. Considerations for future development of B cell-directed therapy for autoimmune diseases have also been discussed.
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Affiliation(s)
- C Hu
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, CT 06520, USA
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